1. NYU Medicine Grand Rounds Clinical Vignette Himali Weerahandi, PGY3 March 6, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 37 year-old woman presenting with abdominal pain for three months. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient was previously in good health, until six months prior when she began experiencing intermittent burning epigastric pain for seven days, triggered after spicy meals. She presented to an Urgent Care Clinic where she was diagnosed with gastroesophageal reflux and started on omeprazole 20mg daily. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Two months later, she re-presented to another medicine clinic with persistent symptoms. During periods of post-prandial epigastric pain, she described intermittent nausea with a few episodes of nonbilious/nonbloody vomiting, and reflux symptoms. She admitted that she was not taking the omeprazole as directed, a half hour before meals. The patient was instructed to take the medication properly, and continued on the omeprazole. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. One month later, the patient returned to clinic with persistence of symptoms. Although she reported mild improvement in reflux symptoms, she had worsening episodes of nausea, vomiting, and abdominal pain. She also reported a two day period of subjective fevers and chills that resolved spontaneously. Because of worsening symptoms, her omeprazole was increased to 40mg daily and she was referred to gastroenterology clinic for an upper endoscopy. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Before her scheduled gastroenterology appointment, she experienced severe worsening of abdominal pain with nausea and vomiting, she presented to the emergency room. There laboratory findings were reportedly normal, and her symptoms were treated and relieved after receiving a “cocktail” of several medications. She was discharged and referred to Bellevue Adult Primary Care Walk-In Clinic for follow-up. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Additional History Past Medical History: No previous medical history Past Surgical History: No surgeries Social History: Denies tobacco or alcohol use Moved to the US from Thailand four years ago Currently not working Family History: Mother: heart arrhythmia Allergies: No Known Drug Allergies Medications: Omeprazole 40 mg daily Pepto-bismol U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Physical Examination General: Young woman in no acute distress Vital Signs: T: 98.3 BP: 97/65 HR:64 RR:14 and O2 sat:100 % on room air Physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Laboratory Findings CBC, Basic Metabolic and Hepatic panels were all within normal limits Helicobacter stool antigen was negative U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Gastroesophageal reflux Gastritis Peptic ulcer disease Cholelithiasis Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Right-upper quadrant abdominal ultrasound –Distended gallbladder “packed” with innumerable gallstones. –No evidence of gall bladder wall thickening or fluid collections suggestive of cholecystitis. Further Diagnostic Tests U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. The patient was referred to general surgery clinic where she was evaluated and underwent elective cholecystectomy. She is currently without symptoms and no longer requires treatment with omeprazole. Outpatient Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Symptomatic cholelithiasis Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS